Document Edv2zmQ0GoX0awzv658xgXe0N

i Environmental Health Associates, Inc. Epidemiologic Study of Vinyl Chloride Workers sponsored by"Chemical Manufacturers Association Please verify or correct the information provided and supply information requested in all blank spots. If information is unknown, indicate with UKN, and if not applicable, NA. EHA USE ONLY Study ID Plant Employee Name 1-5 0? 6-7 (8-21 Last) ssH (22-29 First)' .7S(i>V (30MI) Birthdate // inbnth day year Hire Date ____f(J) , //, 70 month day yeaair Date Last Employed 0/ . 33 ,^? month day year Employment Status 7 as of 12/31/80 y Vital Status as of 12/31/80 If dead: Date of Death ,, month day year Place of Death City, State Foreign Country 31-39 40-45 46-51 52-57 58 59 60-65 66-68 Comments or other information about this employee SAL 000104 i (pSStudy ID JOB HISTORY *****************, ******* PLEASE INDICATE ALL JOBS, LEAVES/TERMINATIONS AND REHIRES BELOW * * * * ****************************** Start Date End Date Job Title Exposed = 1 Unexposed = 0 (6/2373 -L SAL 00010-4552